SECTION 1: REFERRER DETAILS

Referrer Name

Job Title/Role

Organisation

Telephone

Email

Relationship to Client

SECTION 2: CLIENT DETAILS

Full Name

Preferred Name

Date of Birth

//

Gender

CHI Number

Primary Language

Communication Needs

SECTION 3: ADDRESS AND ACCESS

Address

Town/City

Postcode

Home Tel

Mobile

Key Safe Code

Property

Access Instructions

Stairs

Lift

Pets

Smoker

SECTION 4: EMERGENCY CONTACTS

Primary Contact

Name

Relationship

Telephone

Email

Secondary Contact

Name

Relationship

Telephone

Email

SECTION 5: GP AND HEALTHCARE PROFESSIONALS

GP Name

GP Practice

GP Telephone

Community Nurse

Social Worker

Other Professionals

SECTION 6: MEDICAL AND HEALTH INFORMATION

Diagnoses and Conditions

Current Medications

Allergies and Alerts

Cognitive/Mental Health

No impairment

Mild impairment

Dementia

Depression

Anxiety

Psychosis

SECTION 7: CAPACITY AND LEGAL AUTHORITY (AWI Act 2000)

Under the Adults with Incapacity (Scotland) Act 2000, we must consider capacity and legal authority.

Question	Response
Does the client have capacity to consent to care?	Yes No Fluctuating Unknown
Is there a Power of Attorney (Welfare)?	Yes No Unknown
Is there a Guardianship Order?	Yes No Unknown

Attorney/Guardian Details

SECTION 8: SUPPORT NEEDS REQUESTED

Personal Care

Washing

Dressing

Toileting

Continence

Skin Care

Oral Hygiene

Medication Support

Prompting

Administering

Eye/Ear Drops

Creams

Insulin

MAR Chart

Nutrition and Hydration

Meal Prep

Eating Assist

Fluids

Special Diet

PEG Feed

Thickened

Mobility and Transfers

Mobility

Transfers

Hoisting

Turning

Exercises

Falls Prevention

Domestic and Social

Housework

Laundry

Shopping

Companionship

Appointments

Respite

Preferred Visit Times and Frequency

SECTION 9: RISK INFORMATION (For Triage Assessment)

This information is essential for staff safety and appropriate care planning.

Behavioural History

Violence history

Verbal aggression

Physical to carers

Unpredictable

Sexual behaviour

Care resistance

Details of Behavioural Concerns

Environmental Risks

Weapons

Hazardous substances

Poor condition

Trip hazards

Blocked exits

Aggressive pets

Current Risk Status

MH crisis

Stopped meds

Hospital discharge

Substance misuse

Self-harm risk

Safeguarding

Adult Support and Protection Act 2007 — Three Point Test

1. Is the adult unable to safeguard their own wellbeing, property, rights or interests?	Yes No Unsure
2. Is the adult at risk of harm (from self, others, or environment)?	Yes No Unsure
3. Is the adult more vulnerable due to disability, mental disorder, illness, or infirmity?	Yes No Unsure

Additional Risk Information

SECTION 10: CURRENT SERVICES AND CARE PACKAGE

Current Provider

Reason for Change

Funding

Hours/Week

Start Date Required

//

SECTION 11: CONSENT AND DATA SHARING

Consent must be obtained from the client (or legal representative) before making this referral:

The client has consented to this referral

The client consents to information sharing with Cecilia Comfort Care

The client consents to contact with their GP and other professionals

Person Giving Consent

Name

Relationship

Date

//

SECTION 12: REFERRER DECLARATION

I confirm that the information provided is accurate to the best of my knowledge. I understand that Cecilia Comfort Care will use this information to assess suitability for service and conduct risk assessments in accordance with Scottish legislation.

Print Name

Date

//

Contact

Professional Referral Form

Referral Form

Home Care Support Services

SECTION 1: REFERRER DETAILS

SECTION 2: CLIENT DETAILS

SECTION 3: ADDRESS AND ACCESS

SECTION 4: EMERGENCY CONTACTS

Primary Contact

Secondary Contact

SECTION 5: GP AND HEALTHCARE PROFESSIONALS

SECTION 6: MEDICAL AND HEALTH INFORMATION

SECTION 7: CAPACITY AND LEGAL AUTHORITY (AWI Act 2000)

SECTION 8: SUPPORT NEEDS REQUESTED

SECTION 9: RISK INFORMATION (For Triage Assessment)

Adult Support and Protection Act 2007 — Three Point Test

SECTION 10: CURRENT SERVICES AND CARE PACKAGE

SECTION 11: CONSENT AND DATA SHARING

Person Giving Consent

SECTION 12: REFERRER DECLARATION

Submit Referrals to Cecilia Comfort Care

Ready to Discuss Your Care Needs?